It's more than just semantics: For patients and families, it's about making an informed decision.
Could three words change the way
severely ill patients and their loved
ones think about death?
Spiritual leaders and some medical
staff at hospitals across the USA believe
so, and they are reconsidering how
they pose one of life's toughest questions: Do you want to sign a "Do Not Resuscitate" form?
When they ask, family members often balk. They
believe they are giving up, condemning a loved one
Some are now asking the question a different way:
Do you want to allow natural death?
Do not resuscitate. Allow natural death. Both
phrases are uttered at the same time - the moment
when doctors believe they have exhausted
treatment options and death is inevitable.
But Lee Memorial Health System specialists are finding semantics do matter.
"More often than not, the body language of the
family will soften" when the phrase "allow natural
death" is used, says the Rev. Cynthia Brasher,
spiritual services director. "It shifts the burden."
Specific meaning for 'do not resuscitate'
A study published last year in the journal of
Medical Ethics measured how often nurses. student
nurses and people with no health care backgrounds
would endorse allowing death to progress when
they were approached with the phrase "do not
resuscitate" vs. "allow natural death." The nurses
were likely to support the dying process regardless,
but all three groups reported a greater likeliness to
forgo resuscitation if "allow natural death" was used.
Some intensive-care doctors say the words "do
not resuscitate" can't yet disappear. That phrase carries a specific command to the attending medical
Razak Dosani, head of Lee Memorial Hospital's
intensive-care unit, says "do not resuscitate" means
doctors will not perform cardiac resuscitation. But
they will do everything up to that point. That might
not be what the family or patient really wants.
"Allow natural death" suggests doctors will offer only
comfort measures, because any other aggressive
treatment, such as intubation, may only prolong
Intensive-care doctors believe adding new
terminology will help families with their decision.
Only about 20% of Americans have advanced
directives leaving their loved ones to make the call if
they are too sick to do so. Brasher says she knows of
only one other hospital in Florida - the Miami Children's Hospital - that uses similar terminology.
It is not clear, she says, how many other health
organizations across the country use it, but enough
are doing so to pique the interest of scholars who are
studying how words affect end-of-life decisions.
"Our argument is it's more humane and more
compassionate," Brasher says.
Debate drives discussions about death
The semantic shift is a sliver of a broader question:
how to talk about death, disease and the limitations
The conversations are more crucial than ever as
doctors amass an arsenal of technologies to keep
people alive - and a growing list of ethical dilemmas
about the nature of life artificially supported.
"Allow natural death" isn't a new concept.
Sarnira Beckwith, CEO of Hope Hospice in Fort
Myers, says a statewide task force a decade ago
looked at adopting the language on its Do Not
Resuscitate forms. That didn't happen, Beckwith
says, but it got health care providers talking. Hope
Hospice providers use "allow natural death," along
with other terminology, to make sure patients and
family understand their options.
"Our greatest responsibility is to listen to the
person and find the language that is best understood
by them," Beckwith says.
St. David's Health Care in Texas adopted the "allow
natural death" terminology eight years ago,
championed by the manager of spiritual care, the late
Rev. Chuck Meyer, and his successor, the Rev. Arily
"I think people are much more comfortable with
that," says Donahue-Adams, who first introduced
the switch at the system's Round Rock Medical
Center in Texas. 'They hear 'allow natural death' and
say, 'Well, that's exactly what we
want. We want a death that is as natural as possible."
Frank Chessa, director of clinical
ethics at Maine Medical Center,
understands the rationale but
questions its usefulness. He argues the
pluase isn't specific enough.
"'Allow natural death' to my ear is
ambiguous between 'do not
resuscitate' and 'comfort measures
only,'" Chessa says.
He suggests using no such terminology but rather
explaining patients' options with specific examples
of potential life-prolonging therapies.
Many hospitals, Chessa says, are using lengthy,
specific end-of-life order sets to decide on everything
from CPR to dialysis to intubation to blood
Dosani and Marilyn Kole, the Lee Memorial
medical director for intensive care, say explaining
terminology, options and implications of their
choices will allow family members to make the best
decisions for their loved ones.
''That's one of the things lacking in our medical
community," Dosani says. ''We need to take time and